Invited commentary

Abstract

Sarac and colleagues give us an honest appraisal of their experience with SilverHawk atherectomy (FoxHollow Technologies, Redwood City, Calif) for occlusive disease causing limb threat (83%) or claudication (17%). Their general dissatisfaction with the technique emanates from a low observed limb salvage rate of 75% at 1 year, especially in patients presenting with tissue loss. Their compromised results, and those of other single-center studies, contrast the early favorable atherectomy outcomes from the Treating Peripherals with SilverHawk: Outcomes Collection (TALON) registry. A number of factors contribute to outcome variability, including study design (single-center vs multicenter, retrospective vs prospective, consecutive vs noncontinuous patient series), predominant ischemic symptom (claudication vs limb threat), anatomic disease severity (TransAtlantic Inter-Society Consensus classification), completeness and length of follow-up, and how patients were selected for the treatment. This last factor is not well described—nor evident—in many reports and can result in a rather myopic view intrinsic to most single-technique (monotherapy) reports. Without providing a more complete picture of how all patients with limb ischemia are managed at a reporting institution (ie, all therapies offered), the reader is deprived of important details related to patient selection. Ultimately, we want to know what is the best therapy to apply to which patients. With the multitude of available endovascular techniques, including percutaneous transluminal angioplasty, cryoplasty, directional and laser atherectomy, stent, and stent graft, which are effective and should we consider implementing into our revascularization armamentaria? Should we always proceed with an endo-first approach—or alternatively, bypass first for those resisting catheter-based options—or wait for a better-tailored selection algorithm? Unfortunately, such a selection algorithm does not currently exist. Most of us are willing to accept the retrospective nature of most reports and any inherent individual surgeon and institutional biases associated with a description of multiple treatment options. These biases can be minimized using univariate and multivariate statistical analyses to identify prognostic factors associated with observed outcome differences between treatments and patient subgroups. Reports that delineate specific failure modes of individual therapies can also provide useful decision-making information. Although diabetes and tobacco abuse are common in most peripheral arterial disease patients and therefore are not useful discriminators of outcomes, Sarac et al have identified renal disease and tissue loss as predictors of lower postatherectomy patency and limb salvage. It appears that atherectomy provides suboptimal improvements in limb perfusion for patients with advanced tissue loss and that more complete revascularization by bypass construction may be preferred. Much more of the larger algorithm puzzle remains to be solved. Midterm outcome predictors for lower extremity atherectomy proceduresJournal of Vascular SurgeryVol. 48Issue 4PreviewThe performance of atherectomy devices has been variable. The purpose of this study was to evaluate our experience using the SilverHawk atherectomy (Fox Hollow Technologies, Redwood City, Calif) device for lower extremity procedures to determine predictors of midterm success. Full-Text PDF Open Archive